Dr. Ishwarprasad Gilada is among the first infectious diseases experts who raised the alarm against AIDS in India in 1985. He is President of the AIDS Society of India and elected to the Governing Council of International AIDs Society to represent Asia and the Pacific.
He holds the position of Secretary-General of Organised Medicine Academic Guild (OMAG), a federation of 15 professional associations of post-graduate doctors in India, covering 250,000 consultants.
OMAG has issued a press release on July 21 and sought clarification from the ICMR on the statement made by the Minister of State for Health Dr. Bharti Pawar in which she said that no one died due to the shortage of oxygen during the second wave in the country.
OMAG says that though thousands of people may have died as they didn’t get Oxygen in time, yet it was not reported. This is because the ICMR guideline for reporting death during Covid-19 says that asphyxia, respiratory arrest, or respiratory failure cannot be mentioned as a cause of death.
Dr. Gilada in an interview with Outlook clarifies why despite thousands of deaths due to lack of Oxygen, the doctors and hospitals couldn't report it to the government.
Q: Do you agree with the Minister of State’s statement in the Rajya Sabha on July 20 that no one in the country died due to lack of Oxygen?
A: The statement has shocked the medical fraternity because it is far away from the reality that the country witnessed in April and May 2021. People died on roads, in cars, in ambulances, and even in hospitals due to a shortage of Oxygen. The Minister is right in saying that no death was reported due to shortage of Oxygen because the death recording norms don’t allow doctors and hospitals to do so.
It is very interesting to note that the Health Ministry has issued a detailed guideline for reporting deaths but this guideline that the minister referred to was never sent to the states and hospitals across the country.
The states were sent a document by the Indian Council of Medical Research (ICMR) - National Centre for Disease Informatics and Research (NCDIR). This document is called "Guidance for the appropriate recording of COVID-19 related deaths in India". Page 6 of this document categorically says that Asphyxia, Respiratory arrest/Failure, and Respiratory Failure among others cannot be mentioned as a cause of death.
Now, look at another 936-page document, known as "Compendium of Guidelines, Instruction and Standard Operative Procedures for Covid-19”, prepared by the Maharashtra government based on ICMR’s guidelines.
A similar statement concerning the reporting of deaths has been mentioned on page 42. The scenario is almost the same in all the states. Now, tell me how will the doctors and hospitals report death due to shortage of Oxygen when your guideline prohibits us from doing so?
Q: But why do you think ICMR has issued such a guideline? Is the purpose to cover up deaths due to a shortage of Oxygen?
A: I don’t think so. Let me explain to you that when we report the death of an individual, we report the immediate cause of death in the first line, the antecedent cause of death in the second line that covers the name of the disease which caused the death. We also mention additional conditions if any in the third line. This is the system that is being followed.
For example, in death due to Covid-19 in a patient with co-morbidity as diabetes, we will write in the first line the cause of death is Acute Respiratory Distress Syndrome (ARDS), in the second line the antecedent cause is Covid-19, and in the third line, the additional condition is diabetes.
We don’t report a lack of infrastructure or medicine as a cause of death. Let’s presume that a person died due to lack of oxygen or medicine, there is no system to report that. The doctor will never write the person died as he or she didn’t get such or such medicine.
As doctors, we have been taught to avoid mentioning the Mode of dying as the cause of death. The mode of dying doesn’t tell you about the disease due to which the person has died.
Q: Don’t you think instead of saying that no one died due to a shortage of Oxygen, the Minster should have said that there was no system of reporting death due to lack of Oxygen?
A: Yes, that would have been a wise statement. The minister could have expanded her statement a little more to state that "...though some people may have died due to the non-availability of Oxygen initially, our death registry doesn't capture that kind of data."
Q: Do you think during an unprecedented situation like the one we faced during the second wave, the ICMR or the Health Ministry should have instructed the state governments and hospitals to keep a record of all such deaths which happened due to shortage of Oxygen?
A: Yes. That should have been an addendum to the death records and basically, interpretation of the situation surrounding the medical care during the thick of the pandemic and the worst time humanity ever faced the scarcity of Oxygen.
Autopsy or post-mortem can help in cases when the cause of death cannot be ascertained. However, in Covid-19 hardly any autopsies are done due to the fear instilled since the pandemic began, once again due to ICMR guidelines on how dead bodies of Covid-19 patients should be disposed of. At least a few representative Post-Mortems should be done to guide the medical caregivers as well as the authorities. Asphyxia can be then noted in post mortem findings in such cases.
Q: Why did the states, especially those who are in the opposition, not come forward and oppose the Minister’s statement?
A: I am not competent to answer such a question, as I am neither in politics nor in any government position.
Q: Now since there are talks of next waves also, do you think the ICMR or the Health Ministry should rectify the guideline so that at least the country will know the extent of human loss, if any, due to Oxygen shortage in the future?
A: Not necessarily. As the Medical Certification of Cause of Death (MCCD) is an internationally accepted and universal system. However, parallel information can be generated and transmitted from local to state and state to the centre.
Q: Also, do you think a thorough country-wide investigation is required to find out deaths caused by the shortage of Oxygen now?
A: Ideally yes, but practically difficult. Sometimes, death is due to multi-factorial causes, and oxygen can be one of them. Someone can die awaiting an ambulance or the ambulance stuck in traffic or the hospital before being attended by a doctor/healthcare worker. However, it’s very difficult to capture such things as statistics.
Human face and suffering should get priority over statistics and numbers, as there is a German phrase "Statistics do not make you laugh and the figures do not make you cry, it’s the human sufferings that is important".